I was talking with some colleagues of mine recently and we were reviewing bunion surgery, the most common of the elective procedures that we perform. During this conversation, one more experienced colleague said he really does not even need X-rays as he can tell from the clinical evaluation what procedure is going to work out best for the patient. At this point in his career, he feels that getting X-rays is now simply an issue of medicolegal documentation rather than a tool for measuring angles and procedure selection. Most of the others at the table seemed to agree with his philosophy.
I would like to test this colleague’s theory that radiographs really are not necessary for most cases of bunion deformity by asking the readers what procedure they would select based solely upon the clinical evaluation and medical history of the patient presented below as well as the above clinical photos.
A 51-year-old male complains of “bump pain” on the sides of his feet with the left foot worse than the right. He claims the process has been present for years and seems to be getting much worse over the past five years. He denies trauma.
The patient has served as a strength trainer for the past 20 years at a state university so he has been very active and physically fit over the years. The patient recently retired and now drives a truck for pocket change. I asked him if he thinks his pain is in the bump or in the joint. “The big toe has never really moved that much,” he said. “It is the bump that makes it unbearable in shoe gear. If the bump were gone, I would be satisfied.”
He describes the pain as a deep aching sensation when he is off the foot and a sharp, stabbing sensation when he is weight bearing. The intensity of the pain is 5/10 walking into the office but the patient says it can be 10/10 if he is trying to do prolonged weightbearing activity.
He has tried multiple forms of conservative therapy, including modified shoe gear, and oral anti-inflammatory agents such as ibuprofen without significant improvement. The patient is presenting now because the pain has gotten significantly worse over the most recent years and since he is retired, he feels he is in a position to get this addressed. He thinks he would be happy if the bump were simply removed from the left foot.
The patient’s past medical history is benign. He is not taking any medication and has no allergies. His surgical history consists of a tonsillectomy and adenoidectomy in childhood. The patient is single, denies tobacco history and drinks alcohol on very rare social occasions. He denies illicit drug use. A review of his systems is unremarkable.
What The Clinical Exam Revealed
The clinical examination reveals a grossly enlarged prominence about the medial aspect of the first metatarsal of the left foot. Tenderness is evident with manipulation. The hallux is not reducible in the transverse plane despite applying pressure to the medial aspect of the first metatarsal head.
In terms of range of motion, the first metatarsophalangeal joint (MPJ) has 0 degrees of dorsiflexion and 10 degrees of plantarflexion with pain. There is no crepitation with manipulation but this is tempered by the fact that the joint really is not very mobile. The remainder of the MPJs have a smooth range of motion without crepitation and the digits have full ability to bear weight.
The LisFranc’s joint, midtarsal, subtalar and ankle joints also have a smooth range of motion without pain or crepitation. Specifically, there is no evidence of hypermobility or ligamentous laxity within the first metatarsocuneiform joint bilaterally. Localized palpation of the medial eminence is very tender with a firm hypertrophic feel. The right foot has a similar medial eminence prominence that is much smaller as is evident in the above clinical pictures. The range of motion in the right first MPJ consists of 30 degrees of dorsiflexion and 20 degrees of plantarflexion. Otherwise the exam for the right lower extremity is exactly the same as the left extremity.
The patient’s pedal pulses are easily palpable and the capillary fill time is less than three seconds in toes one through five. There is no warmth or erythema within the foot or ankle and hair growth is evident throughout both extremities. In regard to the neurological exam, the epicritic sensorium is grossly intact and is equal bilaterally. There are no motor sensory defects.
The muscle strength about the left first MPJ (extensor hallucis longus/flexor hallucis longus/flexor hallucis brevis) is diminished due to pain at the first MPJ. Otherwise, the intrinsic and extrinsic muscles about the foot and ankle appear to be within normal limits without evidence of atrophy.
I am interested in my readers’ thoughts on what the procedure of choice should be based upon this clinical appearance and clinical findings. I will give you the radiographic visuals after I get a consensus on the proposed procedure. In this exercise, I simply wish to exercise the idea of basing procedure selection solely upon the clinical evaluation and medical history of the patient. I can give you the consensus in the next blog. I am happy to provide further clinical information as desired but I have given you the overall gist of things here.